By Software Magazine Staff
Healthcare technologies secured peak interest in this year’s 2015 Software 500 ranking, which was published in Software Magazine’s November issue. A major shift is occurring throughout the industry, affecting healthcare organizations’ ability to effectively manage claims, payment, and revenue generation. Revenue cycle management (RCM) solutions provide automation, collaboration, and ease of use to streamline billing and collection cycles to address this.
Pressure on the provider comes from trends such as increased patient responsibility and evolving payer/provider roles. “From patient registration to denial management, the revenue cycle requires clean data and automated processes to work efficiently,” states Bob Zimmerman, RCM solution manager, Hyland, creator of OnBase. “Otherwise hospitals risk extending accounts too long and writing them off as a loss.”
RCM tools allow healthcare providers to properly manage their revenue cycles, determining everything from patient insurance and reimbursement eligibility to collecting and properly coding claims to reduce errors and improve profitability.
Latest Trends in RCM
Many challenges of the healthcare industry affect revenue cycles of medical practices from all capacities. “Providers are currently dealing with the dual pressures of declining reimbursements from payers and increasing patient volume,” notes Pradeep Rathinam, head of software enabled business, Harman. He notes that increased regulations, new data standards, changing patient demographics, and evolving reimbursement models all add to the complexity of the healthcare revenue cycle.
Rathinam points out that the Affordable Care Act introduced a series of reforms relating to value-based payments, intended to result in billions of dollars of savings for Medicare and strengthen the care received by Medicare beneficiaries. “It also resulted in a shift to value-based care,” he states.
There is currently a shift in the payer/provider relationship. “Accountable care organizations have bridged gaps between payers and providers with a common objective to reduce the cost of healthcare. Providers are now taking more responsibility for reduction in the cost and are looking for innovative ways to mitigate related revenue realization risks,” says Rathinam. Payers are also investing in provider networks and providers are launching their own healthcare plans. Both payers and providers seem to be aligning towards common objectives.
The change in payer-based reimbursements to higher out-of-pocket liability from the patient is another major trend. “As the cost of healthcare gets more expensive, employers shift the costs to their employees in the form of insurance with higher deductibles and higher co-insurance rates,” says Scott Herbst, SVP/GM, provider solutions, Availity LLC.
“Out-of-pocket expenses for patients in terms of co-pays and deductibles have increased,” acknowledges Rathinam. These higher deductibles combined with increased co-pays impact providers as they are ultimately responsible to ensure delivery and quality of services.
The move from ICD-9 to ICD-10 is an important consideration for healthcare providers and many RCM solutions address the transition.
“With ICD-10 implementation in full swing, health IT vendors are working closely with their customers to fine-tune RCM offerings and ensure better coordination with payers as they begin to settle claims with the new coding system,” says Mark Janiszewski, EVP of product management, Greenway Health. He says that because a growing percentage of a provider’s revenue comes from their patients, more physician practices are evaluating their patient population’s risk profiles to enable informed decisions about their participation in various value-based programs and also help them determine fair costs for services and the outcomes they deliver.
From ICD-10 to health information exchange and data analytics, Zimmerman suggests the key is how to leverage the organization’s talent pool with the available technology solutions. “We are seeing an influx of merger and acquisition activity between both large health systems and the consolidation of smaller practice groups. This results in many organizations struggling with consolidation and standardization of systems and policies,” he offers.
Further, payers and providers are driving efficiency and accuracy through comprehensive automation, data validation, and data integration to reduce costs, remain competitive, and ensure compliance with quality and performance initiatives, suggests Brian Shell, assistant VP, Enterprise Solutions at TriZetto, a Cognizant Company.
He notes major trends as automation, consumerization, collaboration, and pay for performance. “Automation reduces paper forms and manual data handling and allows providers and payers to leverage validated digital information for increased speed and reduced data entry errors,” he offers.
In terms of consumerization, customers now expect cost estimates for services before care is administered, giving them the opportunity to shop around for the best cost/care balance. “Providers are taking the same opportunity to win new patients by providing transparency,” says Shell.
The new era of healthcare is shifting priorities for closer cooperation between entities. “The latest payer/provider collaboration trends are partially the result of savvy providers’ contract compliance efforts,” says Shell. “Providers are getting more creative to find alignment with payers in contract negotiations and ensure accurate payments are collected.”
RCM leaders are looking to automate and digitize processes to enable leaner operations, improve visibility, and reduce error rates.
The pay performance trend—despite mixed results—is rising in popularity and Shell predicts it will become more commonplace over the next two years, requiring organizations and providers to adapt to the new payment models. “Payers and providers have to collaborate to achieve the desired clinical and patient outcomes in pay-for-performance programs. Providers are looking for a solution that helps them operationally manage and analyze their pay-for-performance programs to achieve improved outcomes and increased payments,” says Shell.
Scott Bagwell, president, Experian Health, notes that in this challenging economic environment, it is important for vendors to provide innovative technology and information services that help healthcare organizations improve their bottom line to remain competitive. “Healthcare organizations need systems and solutions that will simplify processes, enable information to be verified and available quickly, and leverage the benefits of automation,” he says.
While the trends in RCM continually change, Bagwell stresses the importance of encouraging greater patient engagement to simplify the patient experience. “With patients wanting and demanding more ownership of their own healthcare, hospitals/healthcare providers must provide an easier and more transparent patient engagement experience,” he adds.
To improve financial outcomes in a healthcare setting, maximizing revenue is essential. “Hospital processes need to be streamlined in such a way that payment delays are avoided,” says Rathinam. He says U.S.-based hospital organizations are continuously looking for improved revenue cycle solutions such as revenue leakage analysis, identification of revenue at risk and touch optimization, billing integrity, analysis of claim denials and under payments, and account receivables analysis.
The latest RCM products and services aim to minimize workflow interruption, reduce manual entry, and validate the completeness of information, suggests Shell. “New solutions have automated repetitive data entry and other processes for dozens of payers and providers across myriad systems, ushering in a new approach to systems interoperability,” he says.
“Broadly speaking, RCM systems can help providers realize greater cash flow from both patients and health plans. However, greater emphasis on value-based care and increasing obligations on the part of the patient to pay for their own healthcare can make selecting a vendor a tricky proposition,” says Herbst. “Does the RCM solution impact end-to-end workflow? Does the solution kick in before the patient walks through your door? Does it make your business staff more efficient and streamlined?” he asks.
The ideal RCM solution streamlines the business side of a medical practice or health system, getting more money per patient quickly and efficiently. “You have to determine if your solution can understand the myriad of rules and nuances of all the different insurance carriers. Can it quickly verify eligibility and benefits prior to the initial encounter? Can it off-ramp patients who may have difficulty paying high deductibles and direct them to other insurance or charity options?”
Finally, does the RCM solution offer business staff options for quickly and methodically identifying and collecting any unpaid claims? “Fundamentally, is your RCM solution positively impacting your cost to collect?” asks Herbst.
To comply with ICD-10, the latest RCM solutions provide claims data to help ensure that physician practices maximize their potential revenue.
Brock Anderson, director, operations, AdvancedMD, suggests top RCM vendors are providing integrated electronic health records (EHR)/practice management (PM) solutions with capabilities to map ICD-9 to ICD-10 with the flexibility to be updated based on payer compliance or noncompliance. Secondarily, he says these vendors provide a robust program to prepare their client base with the knowledge, resources, and tools to successfully bridge the ICD-10 rollout.
Margaret White, president, Aprima RCM, says the best RCM solutions provide an ICD-9/ICD-10 crosswalk and have mechanisms for narrowing down the range of possible ICD-10 codes, “so that the entire universe doesn’t appear every time a provider documents a visit.”
White says the challenge facing all solutions is to update coding documentation so that the patient note supports the ICD-10 coding. “With all systems, some format editing is required. Providers cannot rely solely on software, but need an understanding of ICD-10 coding to meet this challenge.”
Additionally, she says that RCM solutions should differentiate between out of network and in network benefits so providers can collect the correct patient portion prior to treatment.
“Providers who do not have PM software that seamlessly integrates with quality reporting into the EHR will not be ready for pay for performance,” warns White. “Software solutions that require providers to go to third-party sites for physician quality reporting system/clinical quality measures reporting are also not likely to be ready for pay for performance.”
On the Market
A variety of RCM solutions serve the healthcare industry, targeting a range of providers from small to large establishments.
AdvancedMD targets the one- to five-physician market with a focus on preserving independent practice. “Our offering is a full RCM solution that includes EHR, PM, advanced reporting, and services including implementation, active rules development, claims processing, and clearinghouse management, denial management, posting, patient balance management and call center, and client services and consulting.
As far as ICD-10 preparation and tools, Anderson says AdvancedMD has integrated an ICD-10 compliant mapping tool within its EHR and PM solutions. “Prior to going live, AdvancedMD was proactive in providing customers with a dedicated website that included tracking and analysis tools to specifically understand the codes impacted and prepare their practices,” he explains. Medical Billing Services clients also benefit from workflow enhancements and tools targeted at speeding resolution and improving visibility of expected ICD-10 related denials.
To address the trend towards patient balance management and high deductible plans, AdvancedMD provides integrated eligibility and benefit verification with many payers allowing practices to proactively determine patient responsibility, which can be easily posted to a patient’s account prior to service.
Aprima markets EHR, PM, and RCM solutions to physicians in ambulatory practice. “Many physician practices lack the time and expertise to manage appeals and other billing issues that can result in thousands of dollars lost every month,” says White. Aprima RCM provides that focus and expertise, partnering with each practice to help increase reimbursements, speed up payment time, and reduce denials and underpayments.
Aprima RCM features an intuitive crosswalk from ICD-9 to ICD-10, designed with easy-to-follow prompts, according to White. Additionally, the system provides the ability to easily edit physical exam/review of systems when charting. It accommodates out-of-network setup and returns appropriate benefits verification based on in network versus out of network designation.
Aprima RCM also calculates the patient portion of the visit—including both co-pays and deductibles—at time of service and allows fully automated credit card processing of the patient portion after insurance payment is received.
Availity Revenue Cycle Management offers a number of provider-focused solutions to allow healthcare organizations to better manage their business, especially the end-to-end revenue cycle. The solution targets medium to large professional organizations, acute care, critical access hospitals and systems, and post-acute facilities, including hospices and home care arrangements.
“Our suite of products helps providers across the continuum of the revenue cycle—from pre service to post service—by leveraging smart technology and an intuitive interface to help providers receive payments faster while reducing the administrative burden on office staff.
The company focuses on solving pre-service and point-of-service collections as well as post-service billing. “Collecting point-of-service payments can be challenging for providers. Addressing that challenge begins with the patient access process—that part of the revenue cycle where providers first engage with patients. The effectiveness of a practice’s front line team plays a critical role in collections at the point of service and thus, the financial health of the business,” says Herbst.
Availity’s solutions start at pre service, enabling providers to collect more money from their patients upfront because the software allows them to qualify their patient’s eligibility in advance. With its Patient Access solution, the company is able to run a provider’s patients through a broad spectrum evaluation, including determining eligibility and benefits, estimation of service costs based on contracts from providers and health plans, and qualifying patients’ ability to pay.
Greenway Health provides full PM and clearinghouse solutions to office-based physicians that enable these practices to efficiently file claims with insurance providers and collect patient liabilities. The company also offers clinically driven RCM services where it files claims and collects revenue on behalf of customers. Greenway Health targets independent physician practices of any size—ranging from single practitioners to large hospital-owned, multi-specialty practices.
“Greenway Health’s RCM services offer physician practices the tools and training needed to track claims data, ensure accurate and timely claims submissions, boost collection rates, and optimize billing practices. Our RCM team helps customers update and maintain fee schedules and optimize their clinical workflow for peak financial and clinical performance,” says Janiszewski.
The company offers a population health management platform called Greenway Community. It encompasses three major solutions—Greenway Community Analytics, Greenway Community Manager, and Greenway Exchange.
Experian Health provides a single solution for the healthcare industry that redefines revenue cycle efficiency and effectiveness. The company provides technology through every facet of the revenue cycle, including orders and scheduling, patient access, claims and contract management, patient engagement, patient collections optimization, and population health management. From initial patient access to actionable, real-time data and analytics, the eCare NEXT platform combines Touchless Processing and an exception-based workflow to help healthcare organizations achieve payment certainty by automating workflow, optimizing payments from patients and payers, creating business intelligence, and mitigating risk.
“This technology automates up to 80 percent of the pre-registration workflow by identifying and presenting only those patients who need follow up by your staff in order to be cleared prior to arrival. Hospitals and health systems can manage all orders, scheduling, registration, and financial clearance through one solution from one business partner,” says Bagwell.
Experian Health’s target market includes health systems, hospitals, medical groups, and specialty organizations.
Harman has a strategic focus in the healthcare domain with experience and providing RCM services. “We leverage our cloud-based Health SymMetrics analytical framework to provide insights and help healthcare providers with revenue cycle solutions,” says Rathinam.
He says the company has helped U.S.-based providers gain deep insights around the revenue cycle process and create actionable insights, improve outcomes, and reduce time to realized value.
Harman’s RCM solution addresses the latest trends in the healthcare industry and delivers value to providers with a consolidated view of account receivables with advanced visualization, interactivity, and drilldowns for faster analysis; predictive models yielding monthly cash flow forecasts around 95 percent accuracy; insights resulting in identifying which payers are problem payers and where to target for resolution of claims quickly; and touch analysis to help eliminate unproductive touches and streamline revenue cycle operations.
Hyland, creator of OnBase, offers OnBase RCM, which provides the data capture, validation, and automated processes that hospitals require. “As a result, healthcare organizations focus on what brings cash in the door faster—adjudicate more claims, maximizing reimbursements, accelerating cash flow, and decreasing days in accounts receivable.”
The target market for OnBase RCM includes large integrated delivery network/health systems, independent hospitals, physician practice groups, and outpatient organizations of all sizes.
MEDITECH offers a RCM solution that provides integration between office and hospital settings while consolidating scheduling, insurance eligibility, registration, and business office needs. “MEDITECH’s RCM is designed to be centered around the patient/consumer—and the provider. Today, we still see different entities with varied contracts and regulatory requirements that drive billing. We centralize all of the processing for those different entities by providing one statement and one worklist for billers and coders that crosses the continuum. As healthcare moves away from fee for service and into value-based reimbursement, this is the foundation our customers need,” says Melissa Swanfeldt, associate VP, MEDITECH.
As a result of Cognizant’s acquisition of TriZetto late last year, TriZetto expands its beginning-to-end RCM offerings to address the efficiency and accuracy of reimbursement claims required as RCM is transformed from fee-for-service to pay for quality/value models.
TriZetto targets a broad component of healthcare providers and payers. On the provider side, it address facilities from a single physician to hospitals to integrated delivery networks with a variety of patient access, claim submission, and denials management and analytics tools to help streamline revenue cycles. On the payer side, claims adjudication, contract modeling, analytics, and quality and care management platforms address the large national and regional pays, third-party administrators, and more recently, smaller provider-owned plans. “TriZetto seeks to bring additional efficiency and accuracy to all steps of the RCM lifecycle, from the patient’s first interactions to the finalization of payments,” says Shell.
TriZetto has expanded its suite of RCM products and services to include capabilities to further minimize manual entry, increase the speed of data exchange, add further data validation capabilities, and improve automation within current workflow models. With user-friendly validation capabilities and accurate patient price inquiries, the company has added enhancements and further integration with its patient management system and electronic medical record partners to increase efficiencies and offer value-based payment intelligence into the RCM workflow.
As with any other industry, healthcare organizations rely on payment of services to survive. However, this cycle is increasingly complex as the role of the provider and payer evolve with shifting trends in insurance and government mandates. Software solutions, such as RCM, enable providers to better manage the process to ensure payment and offer better value to patients. SW
Dec2015, Software Magazine